Operative

Sample note:
Composite restoration

MOD composite on #19 with local anesthetic, isolation, and shade. Transcript on the left, the note as it appears in CareNotes on the right.

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Dentist and assistant, general practice. Composite was selected before recording. Names, dates, and identifying details are fictional.

What was said

Excerpt. Speech-to-text ran on the phone; this text is all that left the device.

Dentist: Okay, so we're doing the filling on the lower left today, number nineteen, the MOD. Any changes to your health since last time, any new medications?

Patient: No, nothing new. Still just the blood pressure pill. Busy weekend coming up though, my daughter's soccer tournament is Saturday.

Dentist: Good luck to her. Let's get the rubber dam on. Clamp on nineteen.

Dentist: Old amalgam's out. There's recurrent decay under the distal box, I'm going a bit deeper on the distal. Pulp's fine, no exposure.

Dentist: Bite down, tap tap, grind side to side. High on the distal marginal ridge, I'll take that down. Floss passes. You'll be numb for a while, so don't chew on that side until it wears off. Call us if the bite feels high later.

Patient: Will do, thanks.

What CareNotes wrote

The note before the clinician's edits, as it looks on the phone. Scroll the screen; tap a capsule to change it.

Daniel R.

Side Note:
Daughter's soccer tournament this Saturday.
Pt CC:
Replace failing MOD amalgam #19
RMH:
HTN, medicated. NSC.
All risks, complications, alternatives, and benefits discussed, all questions answered.
Exam:
#19 failing MOD amalgam. Recurrent caries at distal box confirmed after amalgam removal. No pulp exposure. Occlusion adjusted on the distal marginal ridge.
Tx:
Composite restoration completed on tooth #[19] under [Lidocaine 2% 1x 1:100K epi] [Local infiltration]. Caries removed and tooth isolated. Etched with [37% phosphoric acid]; [Universal adhesive] applied and cured. [Composite resin] placed; shade [A2]. Occlusion checked and adjusted. [] Numb about 3 hours. No chewing on the left until sensation returns. Call if the bite feels high.
NV:
Recall exam and prophy.

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